Review of Systems (ROS)
General: + weight loss of 25 lbs over the past year; no recent fatigue, fever or chills.
Head, eyes, ears, nose & throat (HEENT): no changes in vision or hearing, no difficulty chewing or swallowing.
Neck: no pain or injury
Respiratory:
CV:
GI:
GU: no urinary hesitancy or change in urine stream
Integument: multiple bruises on his upper arms and back.
MS/Neuro: + falls x 2 within the last 6 months; no syncopal episodes or dizziness
Psych:
Objective Data
PE: B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, ornasopharynx clear, edentulous.
Lungs: CTA AP&L
Cor: S1S2 without rub or gallop
Abd: benign, normoactive bowel sounds x 4
Ext: no cyanosis, clubbing or edema
Integument: multiple bruises in different stages of healing – on his upper arms and back.
Neuro: No obvious deformities, CN grossly intact II-XII.
Write an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with this patient. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 2, “Cultural Competency” (pp. 21–29)Chapter 3, “Examination Techniques and Equipment” (pp. 30-49)
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 1, “Clinical Reasoning, Differential Diagnosis, Evidence-Based Practice, and Symptom Analysis”
